Severe hepatitis with prolonged cholestasis and bile duct injury due the long-term use of ornidazole.

Nitroimidazole derivatives are commonly used in the treatment of protozoal and anaerobic infections, and reports of their hepatotoxicity are rare. We report a case of severe hepatitis due to the long-term (8 weeks) use of ornidazole. A 27-year-old woman presented for evaluation of elevated serum transaminase and total bilirubin levels. Liver biopsy revealed portal inflammation, hepatocellular and canalicular cholestasis, porto-portal and portocentral bridging fibrosis, and a tendency to form nodules. No aetiological factors associated with chronic liver disease were identified. The abdominal ultrasonographic findings were compatible with chronic liver disease. We therefore made the diagnosis of severe hepatitis resulting from the long-term use of ornidazole. We conclude that nitroimidazole derivatives may lead to serious liver damage, especially in female patients.

The effects of Gingko biloba, vitamin E and melatonin on bacterial translocation in thioacetamide-induced fulminant hepatic failure in rats.

BACKGROUND AND STUDY AIMS: Bacterial translocation (BT) has been implicated in the development of infectious complications in many serious clinical conditions such as fulminant hepatic failure (FHF). We aimed to investigate the effects of Gingko biloba (GB), vitamin E (Vit E) and melatonin on intestinal oxidative damage and BT in thioacetamide (TAA)-induced FHF in rats. MATERIALS AND METHODS: A total of 42 rats were divided into five groups. Group 1 (n = 8) was the control group. Group 2 (n = 10) was the TAA group, in which rats received 350 mg/kg TAA daily by the intraperitoneal (ip) route for 3 days. Oral 100 mg/kg GB per day was administered to group 3 (n = 8), oral 200 mg/kg Vit E per day to group 4 (n = 8) and ip 3 mg/kg melatonin per day to group 5 (n = 8) 48 h prior to the first TAA injection and was continued for 5 consecutive days. RESULTS: When compared with the control group, serious hepatic and intestinal oxidative damage, increased Escherichia coli counts in ileal aspirates and high BT frequencies were observed in the TAA group (all p < 0.0001). Only GB treatment attenuated hepatic oxidative damage (p < 0.0001). There was no difference in intestinal oxidative damage, E. coli counts in ileal aspirates and BT frequency between TAA and the other antioxidant treatment groups (p > 0.05). CONCLUSION: Our results suggest that intestinal oxidative damage plays a major role in the development of BT by disrupting the barrier function of intestinal mucosa.

Protective effects of Gingko biloba on thioacetamide-induced fulminant hepatic failure in rats.

Gingko biloba (GB) has antioxidant and platelet-activating factor (PAF) antagonistic effects. We investigated the protective effects of GB on thioacetamide (TAA)-induced fulminant hepatic failure in rats. Fulminant hepatic failure was induced in treatment groups by three intraperitoneal (ip) injections of TAA (350 mg/kg) at 24-hour intervals. Treatments with GB (100 mg/kg per day, orally) and N-acetylcysteine (20 mg/kg twice daily, sc) were initiated 48 hours prior to TAA administration. The liver was removed for histopathological examinations. Serum and liver thiobarbituric acid-reactive substance (TBARS) levels were measured for assessment of oxidative stress. Liver necrosis and inflammation scores and serum and liver TBARS levels were significantly higher in the TAA group compared to the control group (P < 0.001, < 0.001, 0.001, < 0.001, respectively). Liver necrosis and inflammation scores and liver TBARS levels were significantly lower in the GB group compared to the TAA group (P < 0.001, < 0.001 and 0.01, respectively). GB ameliorated hepatic damage in TAA-induced fulminant hepatic failure. This may be due to the free radical-scavenging effects of GB.

Common bile duct diameters after endoscopic sphincterotomy in patients with common bile duct stones: ultrasonographic evaluation.

BACKGROUND: One of the most reliable, frequently used imaging techniques in cholestasis is ultrasonography (US) for the diagnosis of common bile duct (CBD) stones. METHODS: In this study, changes in diameters of CBD were determined ultrasonographically before and after endoscopic sphincterotomy (ES) in 46 patients with stone-induced dilated CBD. RESULTS: There was a significant decrease in CBD diameter measured 1 week after ES and extraction of stone (p < 0.001). In 87% of cases, the difference was more significantly pronounced during the first 24 h of ES. The mean CBD diameters on US were 13.70 +/- 3.00 mm (10-21 mm) before and 9.13 +/- 2.90 mm (4.2-18 mm) 24 h after endoscopic treatment (p < 0.001). After ES, six patients (13%) with inadequate decreases in CBD diameters were found to have residual stones. CONCLUSION: US can show residual stones in the CBD with the same efficacy as endoscopic retrograde cholangiopancreatography.

Serum and ascites fluid cytokine levels in patients with chronic heart failure.

OBJECTIVE: Cytokines that are capable of modulating cardiovascular function were reported to be elevated in patients with advanced heart failure. We evaluated the diagnostic importance of cytokines both in the serum and ascites. MATERIAL AND METHODS: We determined serum and ascites fluid TNF-alpha, IL-1beta, IL-6, IL-8, and soluble IL-2 receptor levels in 14 patients with congestive heart failure (group 1) and in 15 patients with chronic liver disease (group 2). RESULTS: Ascites fluid IL-8 and soluble IL-2 receptor levels were found to be significantly elevated in group 1 when compared with group 2 (p = 0.014 and p = 0.005). There were no statistical differences in serum TNF-alpha, IL-1beta, IL-6, IL-8, and soluble IL-2 receptor levels and ascites fluid TNF-alpha, IL-1beta, and IL-6 levels. Ascites fluid/serum IL-1beta and IL-8 ratio was lower in group 1 when compared with group 2 (p = 0.001 and p = 0.005). Ascites fluid/serum IL-2 and IL-6 ratio was higher in group 1 when compared with group 2 (p = 0.035 and p = 0.025). CONCLUSION: Cytokine levels in ascites fluid, but not in serum, are important in congestive heart failure. Ascites fluid/serum cytokine level ratios were detected to be more conclusive and valid in the diagnosis work-up of ascites aetiology.

The importance of serum and ascites fluid alpha-fetoprotein, carcinoembryonic antigen, CA 19-9, and CA 15-3 levels in differential diagnosis of ascites etiology.

BACKGROUND/AIMS: Clinical usage of tumor markers is being limited due to low specificity. Elevated plasma levels of tumor markers may be seen in diseases other than malignancy, i.e., kidney, liver or circulatory disturbances. METHODOLOGY: In our study, we studied serum and ascites fluid alpha-fetoprotein, carcinoembryonic antigen, CA 19-9, CA 15-3 levels in patients with chronic liver disease, spontaneous bacterial peritonitis, malignancy, tuberculous and congestive heart failure in a total of 76 patients. RESULTS: The sensitivity and specificity for ascites fluid alpha-fetoprotein levels were 28.5% and 100%, for serum alpha-fetoprotein levels 28.5% and 98.1%, for ascites fluid carcinoembryonic antigen levels 38.0% and 98.1%, for serum carcinoembryonic antigen levels 57.1% and 90.0%, for ascites fluid CA 19-9 levels 19.0% and 94.5%, for serum CA 19-9 levels 33.3% and 21.8%, for ascites fluid CA 15-3 levels 28.5% and 92.7%, and for serum CA 15-3 levels 47.6% and 81.8%, respectively. CONCLUSIONS: In conclusion, the sensitivity of serum and ascites fluid tumor markers was found to be low. High specificity may be due to low number of study participants. Serum and ascites fluid tumor markers are not found to be useful in the differential diagnosis of ascites etiology.

Effect of Helicobacter pylori eradication on peptic ulcer disease complicated with outlet obstruction.

BACKGROUND: At present, the prevalence of Helicobacter pylori (H. pylori) in complicated peptic ulcer and the effect of H. pylori eradication on complicated peptic ulcer have not been fully established. In this study, we report the prevalence of H. pylori in peptic ulcer patients complicated with gastric outlet obstruction, effectiveness of oral eradication therapy on these patients, and their long-term follow up. PATIENTS AND METHODS: Ten consecutive patients presenting with clinically and endoscopically significant obstructed peptic ulcers were included in this study. During each endoscopy, seven gastric biopsy specimens were obtained and analyzed for H. pylori colonization. RESULTS: The antral mucosal biopsy specimens were positive for H. pylori in nine patients. H. pylori infection was eradicated and complete ulcer healing was observed in all patients. The mean follow-up period was 14 (7-24) months. One patient had duodenal perforation and underwent surgical intervention following medical treatment, despite the eradication of H. pylori. Ulcer recurrence was noted in two (22.2%) of nine patients, and in one of them the recurrent ulcer was complicated with obstruction (11. 1%). The mean time to ulcer recurrence was 17 months (range, 10-24 months). The biopsies and CLOtests were H. pylori negative at the time of ulcer or erosion recurrence in two patients. CONCLUSION: We suggest that H. pylori eradication may improve the resolution in obstructive ulcer cases with colonization.

The role of axial length in central and branch retinal vein occlusion.

BACKGROUND AND OBJECTIVE: To assess whether the axial length is a local risk factor in central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO). PATIENTS AND METHODS: The axial lengths of affected and fellow eyes of 19 patients with CRVO and 27 with BRVO and of their controls were measured with A-scan ultrasonography. The control group consisted of 17 individuals for CRVO and 25 for BRVO matched in age, sex and the prevalence of hypertension and diabetes in patient groups. The results of measurements in affected, unaffected and control eyes were compared. RESULTS: The mean axial length was different among the affected and unaffected eyes in patients with CRVO and their controls (P < .05). The affected eyes had significantly shorter axial length compared to the fellow and control eyes (P < .01 and P < .01, respectively). In the BRVO group, the mean axial length did not differ among affected, unaffected and control eyes (P > .05). CONCLUSIONS: Our study demonstrates a significantly shorter axial length in eyes with CRVO and not significantly shorter axial length in those with BRVO. The shorter axial length could be an additional risk factor in the pathogenesis of CRVO.

The effect of dividing the sphincter of Oddi at endoscopic sphincterotomy on the filling and emptying aspects of function of the gallbladder.

The effect of dividing the sphincter of Oddi at endoscopic sphincterotomy (EST) on the filling and emptying aspects of gallbladder function has not been definitely established in humans. This prospective study is designed to examine the effects of EST on gallbladder emptying. In 13 patients (8 men and 5 women; mean age, 60.54 years +/- 2.14; range, 45-75 years), postprandial gallbladder emptying was measured ultrasonographically before and after EST (within 1-4 days). The fasting volumes after 8 hours of fasting, at times 0 min and before the test meal was given, residual volume (the smallest postprandial volume), gallbladder ejection fraction (EF), and total ejection volume, at 10, 20, 30, 40, 50, 60, 70, 80, and 90 min after the test meal, were studied. The fasting gallbladder volume and the residual volume tended to decrease after EST, but the differences were not significant (40.21 +/- 10.79 mL and 35.48 +/- 11.21 mL, 17.79 +/- 4.83 mL, and 13.10 +/- 4.83 mL, respectively; p > 0.05). Maximum EF was found to be 19.72% at 40 min and increased to 28.62% at 70 min after EST. Although the difference was not statistically relevant, a trend of improvement was evident after EST. The ejected volumes after EST have depicted a trend toward increase, without reaching to any statistical significance (p > 0.05). Our results demonstrate at least no adverse effects of EST and further support some positive effects on gallbladder kinetics.

Mirizzi syndrome: choice of surgical procedure in the laparoscopic era.

Impaction of a calculus in gallbladder neck or cystic duct or even in its remnant may produce common hepatic duct stricture by direct mechanical impression or associated inflammation. This clinical entity is referred to as Mirizzi syndrome. Four patients were operated on for Mirizzi syndrome. This represents 0.9% of the 444 patients who underwent laparoscopic cholecystectomy in our clinic. Two cases with Mirizzi syndrome type I, one of which had a stone in a gallbladder remnant, were successfully treated by laparoscopic cholecystectomy without any complications. One patient developed a bile leakage; fistulography via a sump drain revealed bile leakage from the laceration site of the stone, and the patient was reoperated on to perform a Roux-en-Y hepaticojejunostomy. The patient was lost due to cardiopulmonary arrest originating from septic shock. In another case diagnosed as Mirizzi type II, the operation was converted to an open procedure due to intense inflammation and fibrosis around the area of the Calot's triangle. Subtotal cholecystectomy was done and the defect on the common hepatic duct repaired by means of a gallbladder flap over the T tube.

Endoscopic treatment of bronchobiliary fistula: report on 11 cases.

BACKGROUND/AIMS: There are reports of treatment of biliary cutaneous fistulae by endoscopically placed nasobiliary drains. We report our fistulae treatment results from this method. MATERIALS AND METHODS: We treated 11 patients with bronchobiliary fistulas (BBFs) endoscopically during the last 6 years. In most cases, the BBF's were the result of Hydatid cyst operations. Six patients had simultaneous biliocutaneous fistula (BCF). RESULTS: All BBFs and BCFs closed after the nasobiliary drain placement without any complication. Three patients who developed fistula recurrence healed with endoscopic treatment. CONCLUSION: Endoscopic treatment is a viable alternative to surgical treatment.

Laparoscopic removal of a gallbladder remnant.

We describe a patient who had an incomplete open cholecystectomy 32 years previously and was hospitalized with jaundice due to a stone in the gallbladder remnant encroaching on the common bile duct. Despite extensive adhesions the gallbladder remnant was removed with laparoscopic techniques and the patient had an uneventful recovery. We conclude that previous surgery, even on the gallbladder, does not preclude the successful completion of a laparoscopic cholecystectomy.